A prospective cohort study of lower-extremity pressure ulcer risk among bedfast older adults.

Pressure ulcers (PrUs) are a common problem in vulnerable individuals, such as bedfast older adults. Patients with PrUs have a reduced quality of life and increased morbidity and mortality rates. Estimates of the incidence of PrUs remain elusive, ranging from 2.2% to 23.9% in long-term-care facilities and 0.4% to 38% in hospitalized patients. As longterm care and hospital populations continue to increase in size as a result of demographic trends, PrUs are anticipated to remain a serious problem for care providers. It has been observed that PrUs in older adult patients occur most commonly on the heel, and the percentages of PrUs are higher on the lower extremities (heel, ankle, foot, and toe) than on the buttocks (sacrum and coccyx). The development of lower-extremity PrUs in the older adult population has become an important issue in Japan. When patients are in bed and immobile, sources of external pressure include the bed surface and friction generated due to movement of the lower extremities as a result of restlessness. The calcaneus is the largest bone in the foot; therefore, the heel and malleoli may be more prone to tissue breakdown than other parts of the body when pressure is exerted directly over the bone because of the small subcutaneous tissue volume in that area. Prevention of PrUs is primarily accomplished by managing tissue loads. Guidelines suggest that PrUs can be prevented by using appropriate support surfaces and turning for patients with limited activity. Moreover, guidelines recommend using pressure-relieving devices on the heels of immobile patients. No detailed guidelines, however, describe preventive care for other parts of the lower extremities. In addition, the use of several risk assessment tools is recommended for risk prediction of PrUs. Predictions are based on the level of consciousness or sensory awareness, mobility, activity, incontinence, nutritional status, friction, and shear. The instruments used to examine these factors were developed for whole-body PrU risk assessment. However, additional factors have been identified that may be important for more precise prediction of the risk of lower-extremity PrU development in bedfast older adult patients. Mayumi Okuwa, MSN, RN; Hiromi Sanada, PhD, RN, WOCN; Junko Sugama, PhD, RN; Michiko Inagaki, PhD, RN; Chizuko Konya, PhD, RN, WOCN; Atsuko Kitagawa, PhD, RN; and Keiko Tabata, RN